=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992174205
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ALISA BESDIN GOLDBERGER
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/16/2015
-----------------------------------------------------
Last Update Date | 09/16/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 135 WILBUR RD
-----------------------------------------------------
City | BERGENFIELD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07621-4036
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-439-9966
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 135 WILBUR RD
-----------------------------------------------------
City | BERGENFIELD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07621-4036
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-439-9966
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | 025853
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------